Nausea After Surgery

FYI, From New York Times, October 3, 2006 (interesting when viewed with the Guidance for FM patients havaing Elective Surgery)

Second Opinion

Answers Fall Short for Nausea After Surgery
By DENISE GRADY

“Thank you for being a part of our study,” said a questionnaire given to surgery patients at Duke University. “We are going to ask you how you feel about postoperative nausea and vomiting.”

Most people could answer with a few choice words, especially anyone who has ever woken up in a recovery room, wretched and retching. Not surprisingly, the patients in the Duke study, published in 2001, rated throwing up as a good thing to avoid.

If only it could be avoided. Somehow, the wonders of modern medicine have not quite reached this queasy zone. Nausea and vomiting, a blight since the dawn of ether, are still among the most common complications of surgery, anesthesia and pain medicine, affecting anywhere from 20 to 80 percent of patients.

Is this really so hard to fix? Or are doctors just too busy with more pressing matters?

“It’s an overwhelming problem,” said Dr. Charles Berde, chief of pain medicine at Children’s Hospital Boston. “It’s right at the center of what everybody who studies postoperative pain tries to deal with. There’s an enormous amount of interest in how to do a better job.”

Part of the problem is that it’s hard to predict who will get sick, because people respond differently to drugs and to surgery. And once the symptoms start, they are hard to quell. Antinausea medicines can help, but not enough, Dr. Berde said.

“In studies, maybe 45 percent will vomit instead of 65 percent,” he said. “In no way does it make the risk very low.”

Some patients are more likely than others to feel ill after surgery: women vomit more often than men, and people who tend to get carsick or seasick have a higher risk. Some get sicker than others; there are people who may vomit for a week after an operation, Dr. Berde said.

Certain operations are more likely to cause the problem, including breast surgery, tonsillectomy, gynecologic procedures and operations on the ears, eye muscles, digestive tract or testes. All can affect nerves that communicate with the brain center that controls vomiting.

The strongest painkillers — morphine and other narcotics related to opium — are notorious for producing nausea, as well as other side effects like itching, constipation, difficulty urinating, paranoia, anxiety, bad dreams and confusion.

“The problem is that morphine and the other narcotics act on pain receptors, but in the same doses also act on receptors in the brain and nervous system that cause nausea and vomiting,” said Dr. Margaret Wood, chairwoman of anesthesiology at NewYork-Presbyterian/Columbia. “Unfortunately, the two are invariably associated. It’s not 100 percent predictable that morphine will always cause nausea and vomiting, but it is very common.”

Often, people who are sent home from the hospital with a prescription for a narcotic are not warned that the drug may make them feel sick, an issue that is growing as more operations are done on an outpatient basis.

“Doctors want to be optimistic,” Dr. Berde said. “They want to be truthful, but in preoperative discussions they often underplay the likelihood of nausea, itching and constipation because they don’t want to make patients worry, and they may believe that focusing on side effects might make them more likely to occur.”

But, he said, the issue has to be addressed.

“People should know that these drugs are useful but they have limitations, and if you’re having vomiting, you should call your doctor and see about trying something different,” he said. Some hospitals, he said, send patients home with antinausea medicine as well, just in case.

But, he added, “patients need to know they can call somebody at midnight after surgery and get clear advice both on managing symptoms and on figuring out when the symptom requires more specific assessment for potential postsurgical problems.”

Even a patient’s own history is not necessarily a good predictor of reactions to a drug. When someone vomits after an appendectomy, was the culprit morphine — or a burst appendix? Some people can tolerate one narcotic but not another, and the only way to find out is by trial and error.

“We are remarkably unscientific about how we take care of this,” Dr. Berde said. “A lot of it is by custom, a lot is by how people got trained.” Sometimes, he added, doctors simply rely on records of what patients were able to tolerate before.

Both he and Dr. Wood said that the best solution is to find ways to minimize the need for the general anesthetics and narcotics that cause so much trouble.

One approach is to use local or regional anesthetics — techniques like nerve blocks and the spinals or epidurals often used for childbirth — to numb the area being operated on before and after surgery. These methods involve the Novocain-type drugs used for dental work. People can still be given medicines to make them sleep through the operation, but the anesthesia does not have to be as deep, and patients need less morphine later or perhaps none at all. These techniques work especially well for operations on the knee, hip and shoulder.

For the orthopedic operations, Dr. Berde said, “the data are very good that you have better pain relief, better rehab and people eat sooner and vomit less.”

The nerve blocks take time to administer, which can clog operating room schedules, but Dr. Berde said some hospitals had solved that problem by setting up separate “induction rooms” where the blocks can be started and given time to take effect before the patient is wheeled into the operating room.

But not all hospitals offer these procedures. Anesthesiologists need special training to administer nerve blocks properly, and qualified ones are more likely to be available at hospitals where a lot of surgery is done. In any case, regional anesthesia is not always possible, Dr. Wood said, noting, for instance, that it is difficult to perform and not always effective for operations on the digestive tract. And spinals and epidurals can have side effects of their own, like headaches and a drop in blood pressure.

After surgery, doctors have also tried using nonnarcotic painkillers like Advil or Aleve to help patients get by with less morphine.

“They are very effective,” Dr. Wood said, but she added that recent reports about small increases in heart risks have made doctors more cautious about using the nonnarcotic drugs. (Tylenol has not been linked to heart problems.)

Dr. Berde has been working with other researchers to try to develop a long-lasting local anesthetic that would work for two days after a single shot and that could be injected into a surgical site before the operation. The research involves a venom from puffer fish and a toxin from algae, both known to cause prolonged numbness. The goal, he said, is to reduce patients’ needs for opiates.

Drug companies are also trying to develop better antinausea drugs, including some that can be given along with opiates to block their effects on receptors in the stomach and brainstem that stimulate vomiting.

Ultimately, the solution may lie in the unfolding science of pharmacogenomics, which deciphers the genetic traits that determine how an individual responds to a particular drug.

“One could hope that out of that will come the prediction that in the future, when you go to preop testing, they will be able to say, we predict that you will do better with fentanyl than morphine, or better with Dilaudid than fentanyl,” Dr. Berde said. “But I think it’s several years away.”

As I am about to have surgery again, I am very apprehensive about the aftereffects. I have always been vry sick with nausea and vomiting. I actually fear the aftereffects more than the surgery.

My plan this time is to get the records of what what given that didn't help me. Because I have a history, this is a good place for me to start. Hopefully, there are some other meds that I can try with success.